{"id":32248,"date":"2023-05-07T13:32:35","date_gmt":"2023-05-07T06:32:35","guid":{"rendered":"http:\/\/noithathoaphat.in\/ctv\/?p=32248"},"modified":"2023-05-18T10:24:01","modified_gmt":"2023-05-18T03:24:01","slug":"thuyen-tac-phoi-va-thai-ky-esc-2019","status":"publish","type":"post","link":"http:\/\/noithathoaphat.in\/ctv\/index.php\/2023\/05\/07\/thuyen-tac-phoi-va-thai-ky-esc-2019\/","title":{"rendered":"Thuy\u00ean t\u1eafc ph\u1ed5i v\u00e0 thai k\u1ef3- ESC 2019"},"content":{"rendered":"

Thuy\u00ean t\u1eafc ph\u1ed5i (PE)\u00a0 c\u1ea5p t\u00ednh v\u1eabn l\u00e0 m\u1ed9t trong nh\u1eefng nguy\u00ean nh\u00e2n h\u00e0ng \u0111\u1ea7u g\u00e2y t\u1eed vong cho s\u1ea3n ph\u1ee5 \u1edf c\u00e1c qu\u1ed1c gia thu nh\u1eadp cao. V\u00ed d\u1ee5, \u1edf Anh v\u00e0 Ireland, huy\u1ebft kh\u1ed1i v\u00e0 thuy\u00ean t\u1eafc huy\u1ebft kh\u1ed1i l\u00e0 nguy\u00ean nh\u00e2n t\u1eed vong m\u1eb9 tr\u1ef1c ti\u1ebfp ph\u1ed5 bi\u1ebfn nh\u1ea5t (t\u1eed vong do mang thai ch\u1ee9 kh\u00f4ng ph\u1ea3i do c\u00e1c b\u1ec7nh l\u00fd tr\u01b0\u1edbc \u0111\u00f3) trong 3 n\u0103m t\u1eeb 2013-2015, d\u1eabn \u0111\u1ebfn t\u1eed vong 1.13 tr\u00ean 100 000 b\u00e0 m\u1eb9.<\/strong><\/p>\n

\"thuyen-tac-phoi\"
\u1ea2nh m\u00f4 t\u1ea3 b\u1ec7nh nh\u00e2n thuy\u00ean t\u1eafc ph\u1ed5i<\/figcaption><\/figure>\n

1. D\u1ecbch t\u1ec5 h\u1ecdc v\u00e0 c\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1 thuy\u00ean t\u1eafc ph\u1ed5i trong thai k\u1ef3<\/strong><\/h2>\n

\u00a0Nguy c\u01a1 VTE cao h\u01a1n \u1edf ph\u1ee5 n\u1eef mang thai so v\u1edbi ph\u1ee5 n\u1eef kh\u00f4ng mang thai trong c\u00f9ng \u0111\u1ed9 tu\u1ed5i; nguy c\u01a1 t\u0103ng l\u00ean trong thai k\u1ef3 v\u00e0 \u0111\u1ea1t \u0111\u1ebfn \u0111\u1ec9nh \u0111i\u1ec3m trong giai \u0111o\u1ea1n sau sinh. Nguy c\u01a1 n\u1ec1n li\u00ean quan \u0111\u1ebfn mang thai gia t\u0103ng h\u01a1n n\u1eefa n\u1ebfu c\u00f3 m\u1eb7t c\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1 VTE \u0111i k\u00e8m, k\u1ec3 c\u1ea3 th\u1ee5 tinh trong \u1ed1ng nghi\u1ec7m: trong m\u1ed9t nghi\u00ean c\u1ee9u c\u1eaft ngang b\u1eaft ngu\u1ed3n t\u1eeb m\u1ed9t \u0111\u0103ng b\u1ed9 Th\u1ee5y \u0110i\u1ec3n, HR cho VTE sau th\u1ee5 tinh trong \u1ed1ng nghi\u1ec7m l\u00e0 1.77 (95% CI 1.41- 2.23) t\u1ed5ng th\u1eddi gian v\u00e0 4.22 (95% CI 2.46-7.20) trong ba th\u00e1ng \u0111\u1ea7u ti\u00ean. C\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1 quan tr\u1ecdng v\u00e0 ph\u1ed5 bi\u1ebfn kh\u00e1c bao g\u1ed3m t\u1eebng b\u1ecb VTE, b\u00e9o ph\u00ec, b\u1ec7nh l\u00fd \u0111i k\u00e8m, thai ch\u1ebft l\u01b0u<\/a>, ti\u1ec1n s\u1ea3n gi\u1eadt<\/a>, xu\u1ea5t huy\u1ebft sau sinh<\/a>, v\u00e0 m\u1ed5 l\u1ea5y thai; \u0111\u00e1nh gi\u00e1 nguy c\u01a1 t\u1eebng \u0111\u01b0\u1ee3c ghi nh\u1eadn tr\u01b0\u1edbc \u0111\u00e2y l\u00e0 r\u1ea5t quan tr\u1ecdng.\u00a0<\/span><\/p>\n

C\u00e1c khuy\u1ebfn c\u00e1o \u0111\u01b0\u1ee3c cung c\u1ea5p trong c\u00e1c ph\u00e1c \u0111\u1ed3 n\u00e0y ph\u00f9 h\u1ee3p v\u1edbi nh\u1eefng \u0111i\u1ec1u \u0111\u01b0\u1ee3c \u0111\u01b0a v\u00e0o H\u01b0\u1edbng d\u1eabn ESC 2018 v\u1ec1 qu\u1ea3n l\u00fd b\u1ec7nh tim m\u1ea1ch trong thai k\u1ef3.<\/span><\/p>\n

2. Ch\u1ea9n \u0111o\u00e1n\u00a0<\/strong><\/h2>\n

2.1 Quy t\u1eafc d\u1ef1 \u0111o\u00e1n l\u00e2m s\u00e0ng v\u00e0 D-dimer<\/a>\u00a0<\/strong><\/h3>\n

Ch\u1ea9n \u0111o\u00e1n PE khi mang thai c\u00f3 th\u1ec3 kh\u00f3 kh\u0103n v\u00ec c\u00e1c tri\u1ec7u ch\u1ee9ng th\u01b0\u1eddng tr\u00f9ng l\u1eb7p v\u1edbi nh\u1eefng thai k\u1ef3 b\u00ecnh th\u01b0\u1eddng. T\u1ef7 l\u1ec7 b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n x\u00e1c \u0111\u1ecbnh PE l\u00e0 th\u1ea5p trong s\u1ed1 ph\u1ee5 n\u1eef nghi ng\u1edd m\u1eafc b\u1ec7nh, t\u1eeb 2 \u0111\u1ebfn 7%. N\u1ed3ng \u0111\u1ed9 D-dimer t\u0103ng li\u00ean t\u1ee5c trong thai k\u1ef3, v\u00e0 n\u1ed3ng \u0111\u1ed9 cao h\u01a1n ng\u01b0\u1ee1ng lo\u1ea1i tr\u1eeb VTE g\u1eb7p trong g\u1ea7n m\u1ed9t ph\u1ea7n t\u01b0 ph\u1ee5 n\u1eef mang thai trong tam c\u00e1 nguy\u1ec7t th\u1ee9 ba. K\u1ebft qu\u1ea3 c\u1ee7a m\u1ed9t nghi\u00ean c\u1ee9u ti\u1ebfn c\u1ee9u \u0111a qu\u1ed1c gia v\u1ec1 x\u1eed tr\u00ed tr\u00ean 441 ph\u1ee5 n\u1eef mang thai \u0111\u1ebfn khoa c\u1ea5p c\u1ee9u v\u1edbi l\u00e2m s\u00e0ng nghi ng\u1edd PE cho th\u1ea5y r\u1eb1ng m\u1ed9t chi\u1ebfn l\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n \u2013 d\u1ef1a tr\u00ean \u0111\u00e1nh gi\u00e1 x\u00e1c su\u1ea5t l\u00e2m s\u00e0ng, \u0111o D-dimer, CUS v\u00e0 CTPA \u2013 c\u00f3 th\u1ec3 lo\u1ea1i tr\u1eeb an to\u00e0n PE trong thai k\u1ef3. Trong nghi\u00ean c\u1ee9u \u0111\u00f3, vi\u1ec7c lo\u1ea1i tr\u1eeb PE d\u1ef1a tr\u00ean c\u01a1 s\u1edf k\u1ebft qu\u1ea3 D-dimer \u00e2m t\u00ednh (kh\u00f4ng c\u00f3 h\u00ecnh \u1ea3nh) l\u00e0 kh\u1ea3 thi \u1edf 11.7% trong s\u1ed1 392 ph\u1ee5 n\u1eef c\u00f3 \u0110i\u1ec3m x\u00e1c su\u1ea5t tr\u01b0\u1edbc c\u1eadn l\u00e2m s\u00e0ng (Geneva) kh\u00f4ng cao, t\u1ef7 l\u1ec7 n\u00e0y gi\u1ea3m xu\u1ed1ng c\u00f2n 4.2% trong tam c\u00e1 nguy\u1ec7t th\u1ee9 ba. M\u1ed9t nghi\u00ean c\u1ee9u ti\u1ebfn c\u1ee9 xa h\u01a1n v\u1ec1 x\u1eed tr\u00ed \u0111\u00e1nh gi\u00e1 s\u1ef1 k\u1ebft h\u1ee3p gi\u1eefa l\u01b0u \u0111\u1ed3 \u0111i\u1ec1u ch\u1ec9nh theo thai k\u1ef3 YEARS v\u1edbi n\u1ed3ng \u0111\u1ed9 D-dimer \u1edf 498 ph\u1ee5 n\u1eef nghi ng\u1edd PE khi mang thai. PE \u0111\u00e3 \u0111\u01b0\u1ee3c lo\u1ea1i tr\u1eeb m\u00e0 kh\u00f4ng c\u00f3 CTPA \u1edf ph\u1ee5 n\u1eef \u0111\u01b0\u1ee3c coi l\u00e0 c\u00f3 nguy c\u01a1 PE th\u1ea5p theo s\u1ef1 k\u1ebft h\u1ee3p c\u1ee7a l\u01b0u \u0111\u1ed3 v\u00e0 k\u1ebft qu\u1ea3 D-dimer. Sau 3 th\u00e1ng, ch\u1ec9 c\u00f3 m\u1ed9t ph\u1ee5 n\u1eef \u0111\u00e3 lo\u1ea1i tr\u1eeb PE d\u1ef1a tr\u00ean l\u01b0u \u0111\u1ed3 l\u00e0 ti\u1ebfn tri\u1ec3n DVT khoeo (0.21%, 95% CI 0.04-1.2) v\u00e0 kh\u00f4ng c\u00f3 ph\u1ee5 n\u1eef n\u00e0o ti\u1ebfn tri\u1ec3n PE.<\/span><\/p>\n

2.2. Ch\u1ea9n \u0111o\u00e1n h\u00ecnh \u1ea3nh\u00a0<\/strong><\/h3>\n

M\u1ed9t l\u01b0u \u0111\u1ed3 \u0111\u1ec1 xu\u1ea5t cho vi\u1ec7c ch\u1ea9n \u0111o\u00e1n khi nghi ng\u1edd PE \u1edf ph\u1ee5 n\u1eef mang thai, ho\u1eb7c \u22646 tu\u1ea7n sau sinh, \u0111\u01b0\u1ee3c hi\u1ec3n th\u1ecb trong H\u00ecnh 7. C\u1ea3 ph\u01a1i nhi\u1ec5m b\u1ee9c x\u1ea1 c\u1ee7a m\u1eb9 v\u00e0 thai \u0111\u1ec1u th\u1ea5p khi s\u1eed d\u1ee5ng c\u00e1c k\u1ef9 thu\u1eadt h\u00ecnh \u1ea3nh hi\u1ec7n \u0111\u1ea1i (B\u1ea3ng 12). \u0110\u1ed1i v\u1edbi x\u1ea1 h\u00ecnh V\/Q v\u00e0 CTPA, li\u1ec1u b\u1ee9c x\u1ea1 c\u1ee7a thai nhi th\u1ea5p h\u01a1n nhi\u1ec1u so v\u1edbi ng\u01b0\u1ee1ng bi\u1ebfn ch\u1ee9ng li\u00ean quan \u0111\u1ebfn ph\u00f3ng x\u1ea1 c\u1ee7a thai nhi (l\u00e0 50-100 mSv). Tr\u01b0\u1edbc \u0111\u00e2y, CTPA \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o g\u00e2y ra ph\u01a1i nhi\u1ec5m b\u1ee9c x\u1ea1 cao \u0111\u1ebfn m\u00f4 v\u00fa; tuy nhi\u00ean, c\u00f4ng ngh\u1ec7 CT \u0111\u00e3 ph\u00e1t tri\u1ec3n v\u00e0 m\u1ed9t s\u1ed1 k\u1ef9 thu\u1eadt c\u00f3 th\u1ec3 gi\u1ea3m ph\u01a1i nhi\u1ec5m v\u1edbi b\u1ee9c x\u1ea1 m\u00e0 kh\u00f4ng \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn ch\u1ea5t l\u01b0\u1ee3ng h\u00ecnh \u1ea3nh. Nh\u1eefng k\u1ef9 thu\u1eadt n\u00e0y bao g\u1ed3m gi\u1ea3m ph\u1ea1m vi gi\u1ea3i ph\u1eabu khi qu\u00e9t, gi\u1ea3m Kilo \u0111i\u1ec7n th\u1ebf, s\u1eed d\u1ee5ng c\u00e1c k\u1ef9 thu\u1eadt d\u1ef1ng h\u00ecnh l\u1eb7p l\u1ea1i, v\u00e0 gi\u1ea3m b\u1edbt th\u00ec theo d\u00f5i c\u1ea3n quang c\u1ee7a CTPA<\/strong> (CTPA c\u00f3 3 th\u00ec: \u0111\u1ecbnh khu b\u1ec7nh nh\u00e2n, theo d\u00f5i c\u1ea3n quang, scan ch\u1ea9n \u0111o\u00e1n). K\u1ef9 thu\u1eadt h\u00ecnh \u1ea3nh CTPA hi\u1ec7n \u0111\u1ea1i c\u00f3 th\u1ec3 ph\u01a1i nhi\u1ec5m m\u00f4 v\u00fa c\u1ee7a m\u1eb9 v\u1edbi li\u1ec1u trung b\u00ecnh th\u1ea5p t\u1edbi m\u1ee9c 3-4 mGy (B\u1ea3ng 12). \u1ea2nh h\u01b0\u1edfng \u0111\u1ebfn nguy c\u01a1 ung th\u01b0 c\u1ee7a m\u1eb9 v\u1edbi k\u1ef9 thu\u1eadt CTPA hi\u1ec7n \u0111\u1ea1i l\u00e0 kh\u00f4ng \u0111\u00e1ng k\u1ec3 (nguy c\u01a1 ung th\u01b0 su\u1ed1t \u0111\u1eddi \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o t\u0103ng theo h\u1ec7 s\u1ed1 1.0003-1.0007); v\u00ec th\u1ebf tr\u00e1nh s\u1eed d\u1ee5ng CTPA v\u00ec l\u00fd do nguy c\u01a1 ung th\u01b0 c\u1ee7a m\u1eb9 l\u00e0 kh\u00f4ng ch\u00ednh \u0111\u00e1ng.\u00a0<\/strong><\/span><\/p>\n

H\u00ecnh \u1ea3nh x\u1ea1 h\u00ecnh t\u01b0\u1edbi m\u00e1u b\u00ecnh th\u01b0\u1eddng v\u00e0 CTPA \u00e2m t\u00ednh l\u00e0 an to\u00e0n nh\u01b0 nhau \u0111\u1ec3 lo\u1ea1i tr\u1eeb PE trong thai k\u1ef3, nh\u01b0 \u0111\u01b0\u1ee3c \u0111\u1ec1 xu\u1ea5t b\u1eb1ng lo\u1ea1t nghi\u00ean c\u1ee9u h\u1ed3i c\u1ee9u. K\u1ebft qu\u1ea3 kh\u00f4ng k\u1ebft lu\u1eadn c\u00f3 th\u1ec3 l\u00e0 m\u1ed9t v\u1ea5n \u0111\u1ec1 (4-33% l\u1ea7n ch\u1ee5p), \u0111\u1eb7c bi\u1ec7t l\u00e0 v\u00e0o cu\u1ed1i thai k\u1ef3. M\u1ed9t cu\u1ed9c kh\u1ea3o s\u00e1t g\u1ea7n \u0111\u00e2y t\u1ea1i 24 \u0111\u1ecba \u0111i\u1ec3m \u1edf Anh, \u0111\u1ea1i di\u1ec7n cho m\u1ed9t d\u00e2n s\u1ed1 15.5 tri\u1ec7u ng\u01b0\u1eddi, cho th\u1ea5y t\u1ef7 l\u1ec7 CTPA v\u00e0 x\u1ea1 h\u00ecnh kh\u00f4ng h\u1ee3p l\u00fd ho\u1eb7c kh\u00f4ng x\u00e1c \u0111\u1ecbnh l\u00e0 g\u1ea7n nh\u01b0 nhau, \u0111i\u1ec1u n\u00e0y g\u1ee3i \u00fd r\u1eb1ng l\u1ef1a ch\u1ecdn ph\u01b0\u01a1ng ti\u1ec7n ch\u1ea9n \u0111o\u00e1n h\u00ecnh \u1ea3nh ban \u0111\u1ea7u t\u1ed1t nh\u1ea5t n\u00ean t\u00f9y thu\u1ed9c v\u00e0o chuy\u00ean m\u00f4n v\u00e0 ngu\u1ed3n l\u1ef1c c\u1ee7a b\u1ec7nh vi\u1ec7n.\u00a0<\/span><\/p>\n

V\/Q SPECT c\u00f3 li\u00ean quan \u0111\u1ebfn ph\u01a1i nhi\u1ec5m b\u1ee9c x\u1ea1 thai nhi v\u00e0 m\u1eb9 th\u1ea5p v\u00e0 h\u1ee9a h\u1eb9n trong ch\u1ea9n \u0111o\u00e1n PE thai k\u1ef3. Tuy nhi\u00ean, \u0111\u00e1nh gi\u00e1 th\u00eam v\u1ec1 k\u1ef9 thu\u1eadt n\u00e0y l\u00e0 c\u1ea7n thi\u1ebft tr\u01b0\u1edbc khi \u0111\u01b0a r\u1ed9ng r\u00e3i v\u00e0o c\u00e1c l\u01b0u \u0111\u1ed3 ch\u1ea9n \u0111o\u00e1n. \u0110\u1ed1i v\u1edbi MRA, t\u00e1c d\u1ee5ng l\u00e2u d\u00e0i c\u1ee7a ch\u1ea5t t\u01b0\u01a1ng ph\u1ea3n gadolinium \u0111\u1ed1i v\u1edbi thai nhi ch\u01b0a \u0111\u01b0\u1ee3c bi\u1ebft \u0111\u1ebfn. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n kh\u00f4ng mang thai, MRA th\u01b0\u1eddng thu \u0111\u01b0\u1ee3c h\u00ecnh \u1ea3nh kh\u00f4ng chu\u1ea9n v\u1ec1 m\u1eb7t k\u1ef9 thu\u1eadt v\u00e0 t\u1ef7 l\u1ec7 cao k\u1ebft qu\u1ea3 kh\u00f4ng k\u1ebft lu\u1eadn \u0111\u01b0\u1ee3c. Do \u0111\u00f3, s\u1eed d\u1ee5ng k\u1ef9 thu\u1eadt n\u00e0y \u0111\u1ec3 ch\u1ea9n \u0111o\u00e1n ho\u1eb7c lo\u1ea1i tr\u1eeb PE trong qu\u00e1 tr\u00ecnh mang thai hi\u1ec7n nay kh\u00f4ng \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o. Ch\u1ee5p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i c\u1ed5 \u0111i\u1ec3n li\u00ean quan \u0111\u1ebfn ph\u01a1i nhi\u1ec5m ph\u00f3ng x\u1ea1 cao h\u01a1n \u0111\u00e1ng k\u1ec3 \u0111\u1ebfn thai nhi (2.2-3.7 mSv) v\u00e0 n\u00ean tr\u00e1nh trong th\u1eddi gian mang thai.<\/span><\/p>\n

\"thuyen-tac-phoi-va-thai-ky\"\"\"<\/p>\n

Ch\u1ea9n \u0111o\u00e1n qu\u00e1 tay PE l\u00e0 m\u1ed9t c\u1ea1m b\u1eaby ti\u1ec1m \u1ea9n c\u00f3 th\u1ec3 \u1ea3nh h\u01b0\u1edfng quan tr\u1ecdng v\u00e0 su\u1ed1t \u0111\u1eddi \u0111\u1ed1i v\u1edbi m\u1ed9t thai ph\u1ee5, bao g\u1ed3m c\u1ea3 nguy c\u01a1 ch\u1ea3y m\u00e1u t\u1ea1i th\u1eddi \u0111i\u1ec3m sinh n\u1edf, vi\u1ec7c t\u1ea1m ng\u01b0ng tr\u00e1nh thai b\u1eb1ng estrogen v\u00e0 y\u00eau c\u1ea7u \u0111i\u1ec1u tr\u1ecb d\u1ef1 ph\u00f2ng huy\u1ebft kh\u1ed1i trong nh\u1eefng l\u1ea7n mang thai k\u1ebf ti\u1ebfp. Do \u0111\u00f3, tr\u00e1nh ch\u1ea9n \u0111o\u00e1n PE qu\u00e1 tay trong thai k\u1ef3 l\u00e0 quan tr\u1ecdng t\u01b0\u01a1ng \u0111\u01b0\u01a1ng nh\u01b0 vi\u1ec7c kh\u00f4ng b\u1ecf s\u00f3t ch\u1ea9n \u0111o\u00e1n PE.<\/span><\/p>\n

2.3 \u0110i\u1ec1u tr\u1ecb PE trong thai k\u1ef3<\/strong><\/h3>\n

\u00a0LMWH l\u00e0 l\u1ef1a ch\u1ecdn \u0111i\u1ec1u tr\u1ecb thuy\u00ean t\u1eafc ph\u1ed5i khi mang thai. Tr\u00e1i ng\u01b0\u1ee3c v\u1edbi VKA v\u00e0 NOAC, LMWH kh\u00f4ng qua nhau thai v\u00e0 do \u0111\u00f3 kh\u00f4ng g\u00e2y nguy c\u01a1 xu\u1ea5t huy\u1ebft thai nhi ho\u1eb7c g\u00e2y qu\u00e1i thai. H\u01a1n n\u1eefa, m\u1eb7c d\u00f9 UFH c\u0169ng an to\u00e0n trong thai k\u1ef3, nh\u01b0ng LMWH c\u00f3 d\u01b0\u1ee3c \u0111\u1ed9ng h\u1ecdc d\u1ec5 d\u1ef1 \u0111o\u00e1n h\u01a1n v\u00e0 \u00edt nguy c\u01a1 h\u01a1n. M\u1eb7c d\u00f9 ch\u01b0a c\u00f3 RCT \u0111\u00e1nh gi\u00e1 li\u1ec1u t\u1ed1i \u01b0u c\u1ee7a LMWH \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb PE trong thai k\u1ef3, d\u1eef li\u1ec7u hi\u1ec7n \u0111\u01b0\u1ee3c c\u00f4ng b\u1ed1 \u1ee7ng h\u1ed9 li\u1ec1u t\u01b0\u01a1ng t\u1ef1 cho b\u1ec7nh nh\u00e2n kh\u00f4ng mang thai, v\u1edbi ph\u01b0\u01a1ng th\u1ee9c o.d. ho\u1eb7c b.i.d. d\u1ef1a tr\u00ean c\u00e2n n\u1eb7ng l\u00fac \u0111\u1ea7u thai k\u1ef3. \u0110\u1ed1i v\u1edbi ph\u1ea7n l\u1edbn b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb LMWH cho PE trong thai k\u1ef3, v\u1eabn kh\u00f4ng ch\u1eafc ch\u1eafn li\u1ec7u \u0111o h\u00e0ng lo\u1ea1t ho\u1ea1t \u0111\u1ed9 kh\u00e1ng y\u1ebfu t\u1ed1 X huy\u1ebft t\u01b0\u01a1ng \u0111\u1ec3 h\u01b0\u1edbng d\u1eabn d\u00f9ng thu\u1ed1c c\u00f3 l\u1ee3i \u00edch l\u00e2m s\u00e0ng g\u00ec kh\u00f4ng. \u0110i\u1ec1u quan tr\u1ecdng l\u00e0 ph\u1ea3i nh\u1edb r\u1eb1ng:<\/span><\/p>\n

\u00a0(i)<\/strong> LMWH c\u00f3 d\u01b0\u1ee3c \u0111\u1ed9ng h\u1ecdc d\u1ef1 \u0111o\u00e1n \u0111\u01b0\u1ee3c,<\/span><\/p>\n

\u00a0(ii)<\/strong> Thi\u1ebfu d\u1eef li\u1ec7u v\u1ec1 n\u1ed3ng \u0111\u1ed9 t\u1ed1i \u01b0u kh\u00e1ng y\u1ebfu t\u1ed1 \u0111\u00f4ng m\u00e1u ho\u1ea1t h\u00f3a,\u00a0<\/span><\/p>\n

(iii)<\/strong> B\u1ea3n th\u00e2n x\u00e9t nghi\u1ec7m c\u0169ng c\u00f3 nh\u1eefng h\u1ea1n ch\u1ebf. Ngo\u00e0i ra, kh\u00f4ng c\u00f3 d\u1eef li\u1ec7u v\u1eefng ch\u1eafc v\u1ec1 l\u1ee3i \u00edch l\u00e2m s\u00e0ng so v\u1edbi t\u00e1c h\u1ea1i c\u1ee7a vi\u1ec7c \u0111i\u1ec1u ch\u1ec9nh li\u1ec1u th\u01b0\u1eddng xuy\u00ean, d\u1ef1a tr\u00ean c\u00e2n n\u1eb7ng c\u1ee7a LMWH khi mang thai. Do \u0111\u00f3, theo d\u00f5i n\u1ed3ng \u0111\u1ed9 kh\u00e1ng y\u1ebfu t\u1ed1 \u0111\u00f4ng m\u00e1u X ho\u1ea1t h\u00f3a c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c d\u00e0nh ri\u00eang cho c\u00e1c tr\u01b0\u1eddng h\u1ee3p nguy c\u01a1 cao c\u1ee5 th\u1ec3 nh\u01b0 VTE t\u00e1i ph\u00e1t, suy th\u1eadn v\u00e0 tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 qu\u00e1 nh\u1ecf ho\u1eb7c qu\u00e1 l\u1edbn.\u00a0<\/span><\/p>\n

Vi\u1ec7c s\u1eed d\u1ee5ng UFH c\u00f3 li\u00ean quan \u0111\u1ebfn gi\u1ea3m ti\u1ec3u c\u1ea7u do heparin v\u00e0 m\u1ea5t x\u01b0\u01a1ng. V\u1eabn kh\u00f4ng ch\u1eafc ch\u1eafn nguy c\u01a1 m\u1ea5t x\u01b0\u01a1ng t\u0103ng l\u00ean khi s\u1eed d\u1ee5ng LMWH \u1edf m\u1ee9c \u0111\u1ed9 n\u00e0o. Trong m\u1ed9t nghi\u00ean c\u1ee9u quan s\u00e1t \u0111o\u00e0n h\u1ec7 g\u1ea7n \u0111\u00e2y, m\u1eadt \u0111\u1ed9 x\u01b0\u01a1ng \u0111\u01b0\u1ee3c \u0111o b\u1eb1ng ph\u01b0\u01a1ng ph\u00e1p h\u1ea5p ph\u1ee5 tia X n\u0103ng l\u01b0\u1ee3ng k\u00e9p 4-7 n\u0103m sau l\u1ea7n sinh n\u1edf cu\u1ed1i c\u00f9ng \u1edf 152 ph\u1ee5 n\u1eef (92 ng\u01b0\u1eddi trong s\u1ed1 h\u1ecd c\u00f3 \u0111i\u1ec1u tr\u1ecb LMWH k\u00e9o d\u00e0i khi mang thai), m\u1eadt \u0111\u1ed9 x\u01b0\u01a1ng c\u1ed9t s\u1ed1ng th\u1eaft l\u01b0ng l\u00e0 t\u01b0\u01a1ng t\u1ef1 gi\u1eefa nh\u00f3m \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng LWMH v\u00e0 nh\u00f3m ch\u1ee9ng sau khi \u0111i\u1ec1u ch\u1ec9nh cho c\u00e1c y\u1ebfu t\u1ed1 c\u00f3 kh\u1ea3 n\u0103ng g\u00e2y nhi\u1ec5u. Kh\u00f4ng c\u00f3 lo\u00e3ng x\u01b0\u01a1ng ho\u1eb7c g\u00e3y x\u01b0\u01a1ng do lo\u00e3ng x\u01b0\u01a1ng \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o.\u00a0<\/span><\/p>\n

C\u00f3 th\u1ec3 xem x\u00e9t fondaparinux<\/strong> thay th\u1ebf n\u1ebfu c\u00f3 d\u1ecb \u1ee9ng ho\u1eb7c \u0111\u00e1p \u1ee9ng b\u1ea5t l\u1ee3i v\u1edbi LMWH, m\u1eb7c d\u00f9 c\u00f2n thi\u1ebfu d\u1eef li\u1ec7u v\u1eefng ch\u1eafc v\u00e0 c\u00f3 qua h\u00e0ng r\u00e0o nhau thai l\u01b0\u1ee3ng \u00edt. VKA qua nhau thai v\u00e0 li\u00ean quan \u0111\u1ebfn b\u1ec7nh l\u00fd ph\u00f4i thai trong tam c\u00e1 nguy\u1ec7t \u0111\u1ea7u ti\u00ean. Cho VKA trong tam c\u00e1 nguy\u1ec7t th\u1ee9 ba c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn xu\u1ea5t huy\u1ebft thai nhi v\u00e0 xu\u1ea5t huy\u1ebft s\u01a1 sinh, c\u0169ng nh\u01b0 bong nhau. Warfarin c\u00f3 th\u1ec3 li\u00ean quan \u0111\u1ebfn d\u1ecb th\u01b0\u1eddng h\u1ec7 th\u1ea7n kinh trung \u01b0\u01a1ng trong b\u00e0o thai trong su\u1ed1t thai k\u1ef3. NOAC l\u00e0 ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh \u1edf b\u1ec7nh nh\u00e2n mang thai.\u00a0<\/span><\/p>\n

Vi\u1ec7c x\u1eed tr\u00ed chuy\u1ec3n d\u1ea1 v\u00e0 sanh<\/a> \u0111\u00f2i h\u1ecfi s\u1ef1 ch\u00fa \u00fd \u0111\u1eb7c bi\u1ec7t. \u1ede ph\u1ee5 n\u1eef \u0111ang \u0111i\u1ec1u tr\u1ecb LMWH, c\u1ea7n xem x\u00e9t sanh ch\u01b0\u01a1ng tr\u00ecnh v\u1edbi ph\u1ed1i h\u1ee3p nh\u00f3m nhi\u1ec1u chuy\u00ean khoa \u0111\u1ec3 tr\u00e1nh nguy c\u01a1 chuy\u1ec3n d\u1ea1 t\u1ef1 nhi\u00ean khi \u0111\u00e3 ch\u1ed1ng \u0111\u00f4ng ho\u00e0n to\u00e0n. T\u1ef7 su\u1ea5t hi\u1ec7n m\u1eafc hematoma t\u1ee7y s\u1ed1ng sau khi g\u00e2y t\u00ea v\u00f9ng \u1edf ph\u1ee5 n\u1eef mang thai \u0111ang \u0111i\u1ec1u tr\u1ecb ch\u1ed1ng \u0111\u00f4ng l\u00e0 kh\u00f4ng r\u00f5. N\u1ebfu xem x\u00e9t gi\u1ea3m \u0111au v\u00f9ng \u1edf m\u1ed9t ph\u1ee5 n\u1eef \u0111ang \u0111i\u1ec1u tr\u1ecb LMWH, c\u1ea7n ch\u1edd \u226524h k\u1ec3 t\u1eeb li\u1ec1u LMWH cu\u1ed1i c\u00f9ng tr\u01b0\u1edbc khi \u0111\u00e2m kim t\u00ea t\u1ee7y s\u1ed1ng ho\u1eb7c kim t\u00ea ngo\u00e0i m\u00e0ng c\u1ee9ng (gi\u1ea3 s\u1eed ch\u1ee9c n\u0103ng th\u1eadn b\u00ecnh th\u01b0\u1eddng v\u00e0 \u0111\u00e3 \u0111\u00e1nh gi\u00e1 nguy c\u01a1 n\u1ebfu tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 qu\u00e1 th\u1ea5p ho\u1eb7c qu\u00e1 cao).\u00a0<\/span><\/p>\n

Trong c\u00e1c t\u00ecnh hu\u1ed1ng nguy c\u01a1 cao, v\u00ed d\u1ee5 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc thuy\u00ean t\u1eafc ph\u1ed5i g\u1ea7n \u0111\u00e2y, LMWH \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o n\u00ean \u0111\u1ed5i th\u00e0nh UFH \u226536 gi\u1edd tr\u01b0\u1edbc sanh. N\u00ean ng\u1eebng truy\u1ec1n UFH 4-6 gi\u1edd tr\u01b0\u1edbc khi sinh d\u1ef1 ki\u1ebfn v\u00e0 th\u1eddi gian thromboplastin ho\u1ea1t h\u00f3a m\u1ed9t ph\u1ea7n tr\u1edf v\u1ec1 b\u00ecnh th\u01b0\u1eddng (t\u1ee9c l\u00e0 kh\u00f4ng k\u00e9o d\u00e0i) tr\u01b0\u1edbc khi g\u00e2y t\u00ea v\u00f9ng.<\/span><\/p>\n

\u00a0D\u1eef li\u1ec7u hi\u1ec7n c\u00f3 v\u1ec1 th\u1eddi gian t\u1ed1i \u01b0u h\u00f3a kh\u1edfi \u0111\u1ed9ng l\u1ea1i LMWH sau sinh th\u00ec h\u1ea1n ch\u1ebf. Th\u1eddi gian s\u1ebd ph\u1ee5 thu\u1ed9c v\u00e0o ph\u01b0\u01a1ng ph\u00e1p sanh v\u00e0 \u0111\u00e1nh gi\u00e1 l\u1ee3i h\u1ea1i gi\u1eefa nguy c\u01a1 huy\u1ebft kh\u1ed1i v\u00e0 nguy c\u01a1 ch\u1ea3y m\u00e1u b\u1edfi nh\u00f3m \u0111a chuy\u00ean khoa. Kh\u00f4ng n\u00ean cho LMWH cho \u0111\u1ebfn khi \u22654 gi\u1edd sau khi l\u1ea5y catheter ngo\u00e0i m\u00e0ng c\u1ee9ng; quy\u1ebft \u0111\u1ecbnh v\u1ec1 th\u1eddi gian v\u00e0 li\u1ec1u l\u01b0\u1ee3ng n\u00ean xem x\u00e9t li\u1ec7u l\u00fac \u0111\u01b0a catheter v\u00e0o khoang ngo\u00e0i m\u00e0ng c\u1ee9ng c\u00f3 t\u1ed5n th\u01b0\u01a1ng g\u00ec hay kh\u00f4ng, v\u00e0 t\u00ednh \u0111\u1ebfn c\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1 c\u1ee7a ng\u01b0\u1eddi ph\u1ee5 n\u1eef. V\u00ed d\u1ee5, m\u1ed9t li\u1ec1u t\u1ea1m th\u1eddi LMWH d\u1ef1 ph\u00f2ng c\u00f3 th\u1ec3 c\u00e2n nh\u1eafc cho khi h\u1eadu ph\u1eabu (sau khi m\u1ed5 l\u1ea5y thai), \u00edt nh\u1ea5t 4 gi\u1edd sau khi catheter ngo\u00e0i m\u00e0ng c\u1ee9ng \u0111\u01b0\u1ee3c l\u1ea5y ra v\u00e0 cho ph\u00e9p m\u1ed9t kho\u1ea3ng \u22658-12 gi\u1edd gi\u1eefa li\u1ec1u d\u1ef1 ph\u00f2ng v\u00e0 li\u1ec1u \u0111i\u1ec1u tr\u1ecb ti\u1ebfp theo. Ph\u1ed1i h\u1ee3p ch\u1eb7t ch\u1ebd gi\u1eefa b\u00e1c s\u0129 s\u1ea3n khoa, b\u00e1c s\u0129 g\u00e2y m\u00ea v\u00e0 b\u00e1c s\u0129 \u0111i\u1ec1u tr\u1ecb ch\u00ednh \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o.<\/span><\/p>\n

\u0110i\u1ec1u tr\u1ecb ch\u1ed1ng \u0111\u00f4ng m\u00e1u n\u00ean \u0111\u01b0\u1ee3c d\u00f9ng ti\u1ebfp \u22656 tu\u1ea7n sau khi sinh v\u00e0 v\u1edbi t\u1ed5ng th\u1eddi gian \u0111i\u1ec1u tr\u1ecb t\u1ed1i thi\u1ec3u l\u00e0 3 th\u00e1ng. LMWH v\u00e0 warfarin c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c d\u00f9ng cho c\u00e1c b\u00e0 m\u1eb9 cho con b\u00fa; vi\u1ec7c s\u1eed d\u1ee5ng NOAC kh\u00f4ng \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o.<\/span><\/p>\n

\u00a0PE nguy c\u01a1 cao, \u0111e d\u1ecda t\u00ednh m\u1ea1ng khi mang thai l\u00e0 m\u1ed9t s\u1ef1 ki\u1ec7n hi\u1ebfm g\u1eb7p nh\u01b0ng r\u1ea5t tr\u1ea7m tr\u1ecdng. M\u1ed9t t\u1ed5ng quan h\u1ec7 th\u1ed1ng g\u1ea7n \u0111\u00e2y bao g\u1ed3m 127 tr\u01b0\u1eddng h\u1ee3p PE n\u1eb7ng khi mang thai (v\u00e0 cho \u0111\u1ebfn 6 tu\u1ea7n sau sinh) \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng ti\u00eau s\u1ee3i huy\u1ebft, l\u1ea5y huy\u1ebft kh\u1ed1i v\u00e0\/ho\u1eb7c ECMO. Trong \u0111\u00f3 bao g\u1ed3m c\u00e1c tr\u01b0\u1eddng h\u1ee3p PE nguy c\u01a1 cao v\u00e0 trung b\u00ecnh, v\u00e0 23% ph\u1ee5 n\u1eef c\u00f3 ng\u1eebng tim. T\u1ef7 l\u1ec7 s\u1ed1ng s\u00f3t \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o l\u00e0 94 v\u00e0 86% t\u01b0\u01a1ng \u1ee9ng v\u1edbi sau khi ti\u00eau s\u1ee3i huy\u1ebft v\u00e0 ph\u1eabu thu\u1eadt l\u1ea5y huy\u1ebft kh\u1ed1i; tuy nhi\u00ean, c\u00e1c t\u1ef7 l\u1ec7 cao n\u00e0y c\u00f3 th\u1ec3 ph\u1ea3n \u00e1nh sai s\u1ed1 trong b\u00e1o c\u00e1o. Khi d\u00f9ng ti\u00eau s\u1ee3i huy\u1ebft, ch\u1ea3y m\u00e1u l\u1edbn x\u1ea3y ra \u1edf 18% c\u00e1c tr\u01b0\u1eddng h\u1ee3p trong th\u1eddi k\u1ef3 mang thai v\u00e0 58% trong giai \u0111o\u1ea1n sau sinh. Cu\u1ed1i c\u00f9ng, thai ch\u1ebft x\u1ea3y ra \u1edf 12 v\u00e0 20% l\u1ea7n l\u01b0\u1ee3t c\u00e1c tr\u01b0\u1eddng h\u1ee3p sau ti\u00eau s\u1ee3i huy\u1ebft v\u00e0 l\u1ea5y huy\u1ebft kh\u1ed1i. \u0110i\u1ec1u tr\u1ecb ti\u00eau s\u1ee3i huy\u1ebft kh\u00f4ng n\u00ean \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng chu sanh, ngo\u1ea1i tr\u1eeb trong tr\u01b0\u1eddng h\u1ee3p PE \u0111e d\u1ecda t\u00ednh m\u1ea1ng. Th\u00f4ng th\u01b0\u1eddng, UFH \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong \u0111i\u1ec1u tr\u1ecb PE c\u1ea5p t\u00ednh nguy c\u01a1 cao.\u00a0<\/span><\/p>\n

M\u1eb7c d\u00f9 c\u00e1c ch\u1ec9 \u0111\u1ecbnh cho l\u01b0\u1edbi l\u1ecdc t\u0129nh m\u1ea1ch ch\u1ee7<\/strong> t\u01b0\u01a1ng t\u1ef1 nh\u01b0 b\u1ec7nh nh\u00e2n kh\u00f4ng mang thai, tuy nhi\u00ean kinh nghi\u1ec7m s\u1eed d\u1ee5ng l\u01b0\u1edbi l\u1ecdc trong thai k\u1ef3 kh\u00f4ng nhi\u1ec1u, v\u00ec th\u1ebf nguy c\u01a1 li\u00ean quan \u0111\u1ebfn th\u1ee7 thu\u1eadt c\u00f3 th\u1ec3 t\u0103ng l\u00ean. <\/span><\/p>\n